Diagnosis Morbus Hansen with ENL Reaction

Name : Mr. Heru Setiawan

Age : 26 years old
Address : Jl. Nuri
Date admission : September 3rd 2018
18 days of treatment
Chief complaint : redness patch at face, both hands and legs

September 3 rd 2018 (Day 1)

Subjective :
A man, 26 years old admitted to the hospital with a chief complaint redness patch at face, both
hands and legs with redness lumps 3 days before admitted. Initially, the patch at face, both hands
and legs are brownish since 3 months ago but worsen. History of multi drug treatment (MDT)
from puskesmas for 12 months in 2016 and was stated release from treatment (RFT). History of
Prednisone consumption from hospital in Timika (+) since 3 months until now. History of ROM
treatment a week ago in UNHAS Hospital. History of medicine and food allergy (-). History of
diabetes mellitus (-). History of hypertension (-).

Objective :
Dermatology status
Region : facial, superior and inferior extremities
Efflorescence: erythematous nodules, edema, erythematous macules, hyperpigmentation macules

Assessment :
Morbus Hansen with ENL Reaction
Depending Steroid

Planning :
- Infuse Ringer Lactate 20 drops per minute
- Vitamin C injection 1amp/24hours/IV
- Dexamethasone injection 1 amp/12 hours/IV
- Paracetamol 500mg/8hours/oral
- Rifampicin 600mg/oral/ 3x1 week
- Ofloxacin 400mg/oral/ 3x1 week
- Minocyclin 100mg/oral/ 3x1 week
- Waiting for laboratory results
- Planning for biopsy
- Planning for BTA staining